F0684

D

Failure to Assess and Treat Diabetic Ulcer and Head Injury for Two Residents

Council Bluffs, Iowa Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate assessment and treatment for a diabetic foot ulcer for one resident and failure to appropriately assess and monitor a head injury for another resident. For the first resident, the admission/readmission progress note dated 1/5/26 documented no impaired skin integrity, including no diabetic ulcer or open areas, despite the resident later being identified as having a diabetic ulcer on the second digit of the left foot. The resident, who had a BIMS score of 15 indicating no cognitive impairment, reported that she had informed the RN/ADON about the sore on her foot and that nothing was done until another RN intervened. The electronic health record showed that a wound evaluation entered on 1/15/26 documented a diabetic ulcer on the left second toe, present on admission, with specific measurements and description, and physician notification at that time.

Further review of the records for this resident showed that the wound was again evaluated on 1/16/26 and 1/23/26 with documented measurements, but there was no documentation of any physician notification or treatment for the wound from the time of admission on 1/5/26 until 1/15/26, when the RN first addressed the area. A physician’s order to cleanse the second toe on the left foot and apply triple antibiotic ointment with a bandage daily had a start date of 1/15/26, indicating that treatment was not initiated until ten days after admission. The DON stated that the initial admission skin assessment was completed by one RN who left without documenting the assessment, and that the evening nurse then completed the assessment again. The DON also stated she did not think the initial nurse observed the resident’s foot or toe, acknowledged that the wound should have been noticed on admission, and confirmed that the resident was in the facility for a week without the wound being assessed or treated.

For the second resident, who had a BIMS score of 13 indicating no cognitive impairment, the facility failed to appropriately assess and monitor a head injury and associated bruising. A skin check dated 12/22/25 documented no skin issues. On 1/4/26 in the morning, an LPN observed a scratch or red mark on the right side of the resident’s forehead and obtained an initial set of vital signs and an assessment as part of the daily assessment, but did not initiate neuro checks at that time and did not remove the resident’s clothing to assess hips or buttocks, only pulling pant legs up. The LPN reported conflicting accounts from the resident about how the injury occurred and stated she was not aware of any procedure for injury of unknown origin or for witnessed/unwitnessed head injury. Later that day, when the resident’s daughter arrived, the area on the forehead had progressed to a swollen “goose egg,” at which point neuro checks were started and the on-call provider was notified, with documentation showing neurological assessments beginning at 6:00 PM and a skilled note at 7:49 PM describing a hematoma to the right forehead and notifications made.

The resident’s daughter reported finding her mother with a bruise on the knee and a wound on the right side of the head, and stated the resident told her she had fallen in the bathroom that morning. She also reported that additional large bruises on the right hip and right shoulder blade were only discovered and brought to attention when the resident was examined in the emergency department the following day. The DON acknowledged that there had been an injury of unknown origin and that staff had not notified the physician or family appropriately when the injury was first found in the morning, and that neuro assessments should have been initiated at that time but were not. The DON stated she would have expected staff to notify her, the physician, and the family when the head injury was first observed at approximately 7:30 AM, and confirmed that these actions were not completed as expected. The nurse practitioner stated she was notified of the forehead area and conflicting stories but was not made aware of the goose egg or any other bruising, and that she would have expected staff to call with any head injuries and start neuro assessments immediately.